In this episode, Josh spoke with Sachin Jain, MD, MBA, the President and CEO of SCAN Group and Health Plan. This is the second of two condensed parts of the conversation between Dr. Liao and Dr. Jain, and has been edited for clarity and length.
Joshua Liao: What would you say to somebody that says I’m interested in [using payment innovation to care for high need populations such as unhoused individuals]; I am not as optimistic but also not like “good luck”. What are two or three things people can think about to understand whether they are ready for this?
Sachin Jain: Stop thinking small. We live in this horrible game of incrementalism coupled with watching really bad sequels play out over and over again. I think we have a consistent failure to learn from the lessons of yesterday, and a consistent failure from the industry to say out loud that this has been done before. What I would say is, focus on what is truly different here. What is truly different here is that we’re actually targeting the highest cost, highest need population, we’re bringing a new approach to health care payment to the game.
And let’s give less attention to the over-hyped, re-hashed sequels that aren’t really moving the needle.
High cost, high need patients are going to need high cost, high need interventions to really solve their problems. There’s a predictable set of issues that come up with all of this: patient selection, intensity of service delivery, patient engagement. We’re at a moment where we are trying to take all of these lessons that have been learned across all these different experiments that have been done in this space, and bring them together to solve this problem.
I’m the last person to hype it and say this is definitely going to work, which is what you’d hear from most people about this. I don’t know; I hope it will. I think society needs this to work, and I need everyone’s help to make it work. That’s what I would tell them.
JL: Much in my view of how we’ve thought about what works is: what happens to total cost of care, and does cost go down? To your point about moral imperative – and paying more because you should, to get more health as an output of that – how will you think about success with this program?
SJ: I love this question and I’ll take it at a broader level for a second. People are lost in this morass of is Medicare Advantage cheaper than fee-for-service. Very few people are asking the more important question, which is: is Medicare Advantage better than fee-for-service?
If you ask most seniors who enrolled in it, heck ya, it’s better. It’s lower cost of care out of pocket; it’s more benefits. We’re still debating whether dental and vision should be included in the fee-for-service Medicare program. Most Medicare Advantage (MA) plans have had dental and vision coverage for most of their history. So, I think your question – which is about the total cost of care measured on an annual basis but doesn’t really look at health outcomes – is a great one. I think we should be looking at health outcomes and we should be looking at other end points like, how many of these people do get housed? Because I think that is a true quality of life measure, and it is something we’re tracking.
I think when this experiment reaches what you all call an intermediate end point, one of the questions we need to be asking is: are people better housed? Are their illnesses under better control? Or are we just bringing a fancy fee-for-service model, paying for it a little bit differently, dumping clinicians on the streets, and saying “good luck”? Hopefully that’s not how it plays out, but I think we need to be constantly asking those questions.
JL: You talked about your experience in the past in public service and government. This issue of MA and fee-for-service. In some of the groups that I talk to, there’s a sense that MA is inevitable – everyone’s going to MA. Other people say we want to bring along fee-for-service to be comparable, and innovate in that space as well. How could you see some of these value-based payment models in fee-for-service, Medicare otherwise, really elevate to be comparable to some of the things you’re seeing in MA?
SJ: I think the first question is “better for whom?” Is it better for the patients? Better for the clinicians? Better for the payers? Better for the health systems and health plans?
In a piece I wrote in Forbes, Everybody’s Talking About Value-Based Health Care. Here’s What They’re Not Saying, I [make the point that] everyone loves to talk about the value equation and people talk about value-based care about being the ratio of quality over cost. But the fastest way to create value is actually not to improve quality, it’s to reduce cost. Most levers within both MA and as well as a lot of other value-based payment models on the cost equation, not as much on the quality equation.
What we have to be looking at is: how do we create clinical cultures that are actually aligned mostly around doing the right things for patients, in whatever payment model. I think that’s gotten a little bit lost as we focus more and more about how we get paid, as health care as become more and more of a true business. We’re not having those quaint conversations that we ought to have around the values of the people who are delivering the care and organizational culture. That is what I think is going to preserve great outcomes for patients rather than getting the payment models right.
JL: We often ask, “what are the things we need to do to get us toward progress”? I’m going to ask you the opposite: what are the few things that we need to take a way – whether it’s an idea, a framing, a payment approach or model of care – to get us toward progress?
SJ: I think we have to get out of the way, number one, the orientation in health care to study it forever before actually believing it. Health services research has become an industry unto itself. We don’t believe it has happened unless an investigator has created a carefully studied randomized controlled trial and has evaluated it.
Number two, we have to get out of the mindset that digital is going to solve everything. I think the pendulum has swung way too far. There’s no one keeping an eye on the total experience for the patient, and by creating a lot of verticals without the view to integrate things, that’s been a real problem.
Number three, we have to create national regulation around interoperability and transferability of peoples’ medical records. Right now, peoples’ medical records are considered a corporate asset that has to be defended, protected, preserved. I think we missed the boat in HITECH when building the Meaningful Use Regulations; emphasis number one should have been on interoperability and transferability of health information. I think that’s something we have to get to.
JL: I appreciate your candor around the challenge of studying too much.
SJ: To make it less abstract, I want to double click on the difference between how ORDI, which was the predecessor organization to CMMI, worked and how CMMI is working in practice right now. ORDI, in the 80’s, tested DRGs for a few different cardiac conditions. They tested in one state, New Jersey, at a cost of double digits millions. Based on that, CMS then built the entire DRG system which dominates how we pay for health care. Look – there’s problem with the DRG system; there’s going to be problems with every system. But the point is we were able to flip the switch and reduce the length of stays in hospitals across the country by introducing DRGs. And we did it by testing it one place, in one geography, with a few sets of conditions to prove that it worked.
We don’t do that anymore. We have to study it, and study it again. When we were starting CMMI, this was a fundamental question we were grappling with: what is the evidence threshold that you have to establish to be able to scale things? We should be flipping switches much more. I think we have a consensus driven implementation and leadership model in health care and we’re always worried about the exceptions, and enable all kinds of other of things to happen because we’re worried about the exceptions. There’s a culture of how we change health care that has to change.
JL: Let me ask a follow-up on this cultural point. I find that often, it’s the idea in the room that when someone utters it and no one stops to “road test” it – those are the ones we have to stop and unpack a little bit. How [should we use] either evaluation or other policy evaluations to slow up and make sure that we adjust the pendulum?
SJ: Sometimes you have to slow down to speed up. There’s this moral high ground that people take in these meetings, “no margin no mission.” I don’t think most health care organizations have actually grappled with whether the mission that they’re pursuing is the mission they ought to be pursuing.
One of the reasons the kinds of stuff that you and I care about gets held up is because there’s surface level alignment, but there isn’t really deep alignment. There’s the stated lens and the unstated lens. The stated lens is what’s just for the patients. The unstated lens is what’s good for our bottom line in the current environment.
I think [the things that we care about but aren’t getting done] aren’t getting done because we have not grappled with this deeper question, which is that American health care over the last 30 or 40 years went from being mission driven to being almost entirely corporatized. And everyone is hiding behind this “no margin, no mission” thing. No one is asking: “is our mission just?” So, if you’re a health system, you’re not asking, is it just that the people are being admitted to our hospital? If your mission is to keep people healthy, then your mission should be to keep people out of your hospital. Which should then translate into, let’s adopt [different] kinds of payment models. At the board level, at the senior management team level, there’s not enough of that conversation going on, because what success looks like is making your numbers in 2022 look better than your numbers were in 2021.
But what is better? Better means fewer and sicker patients, better management of chronic disease. We can all agree on those things. But at the end of the day, if the bottom line metric that your board is judging you by is, “did the numbers go up?”, then you’re always going to be in this moral dilemma. And I think this is where a lot of burnout comes from. A lot of moral injury happens when your stated intent is different from the behaviors you’re actually performing every day. That’s where I think we need to spend more effort.
JL: This idea of equity, and really getting at the foundation of it, is really important. Is there anything else you want to share form your perspective?
SJ: No, great conversation; it’s always fun to talk to you Josh, and appreciate the opportunity.